Exostosis confusion and podiatry coding confusion

nsteinhauser

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Please help - any thoughts would be appreciated! Here's an op note:

..".Attention was directed to the dorsum of the right mid foot in between the tibialis anterior tendon and EDL tendon along the lateral margin of the tibialis anterior tendon. Subcutaneous tissues were dissected. Longitudinal capsulotomy subperiosteal dissection was done at the second cuneiform metatarsal base and proximal to this. What appeared to be a traumatic neuroma appeared. This was excised. Some of the deep subfascial tissues were collected and labeled neuroma, deep cyst, right foot. The tibialis anterior tendon sheath had no longitudinal splits and the area appeared helathy. The tendon sheath did have some fibrillation, which was debrided and subsequently repaired utilizing 2-0 Vicryl stitch. Prior to the tendon repair, sagittal saw and hand rasp was done to debulk the area dorsally where the exostosis was. Forefoot was loaded and no bony prominences remained. Bone wax was applied following irrigation utilizing sterile saline solution. Bone wax was fitted. Tibialis anterior tendon sheath was repaired utilizing 2-0 Vicryl stitch, reinforced with 2-0 silk, subcu 3-0 Vicryl, skin 4-0 nylon............"

28080 for the neuroma .... but can I also code for a tarsal exostectomy...but it was all done through the same incision....??? The path report was just the neuroma so there was no 'bone cyst or benign tumor' that was turned in. So- if I CAN code additionally for the exostectomy.... I've read so many conflicting reports about the cpt to use...some people say if it's just documented as exostosis, to use the 'bone cyst or benign tumor' 28104 - but some people say if it's not documented as a 'bone cyst or benign tumor', you can't use the 28104, you should use the 28122 - the partial excision of bone.

Any thoughts on this would be greatly appreciated!:confused:
 

PLAIDMAN

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I would use the 28122- I was taught "bossing" is same as exostosis.

You will have to pick your codes- then look to see if codes are included with each other(under medicare or commercial)

my orthopaedic dictionary definition for bossing (28122) is "rounded prominence of bone that is abnormally visible under the skin" - exostosis "excess bone formation"

It may not necessarily be "visible" but they are both bony prominences.

I would think 28122 would be most appropriate, I would not code something the doc specifically says is an exostosis, as a tumor or cyst.

Sounds good right?
 

nsteinhauser

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Thank you for your thoughts. Seeeee - that's what I always thought, too. Exostosis is NOT the same as a bone cyst/benign tumor. I read somewhere years ago the same thing you mentioned - 'bossing' should point you to 'removal of bone or excess bone' as in 'part of the bone' as in 28122.

BUT - look at the CPT section for leg and ankle joints.

Underneath 27640 and 27641, there's a highlighted note under each one of those codes that reads: "For exostosis excision, use 27635." And 27635 is - you guessed it - "excision or curettage of bone cyst or benign tumor"

So - I'm still wondering.
 

PLAIDMAN

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I am going to go ahead and assume this is because the leg does not have specific codes to address these types of problems, as the foot does. I work with pods and orthos and I almost never see an exostosis of the leg, every once in a while I will see one on the prox tib. so I think they just do not have specific codes in leg???
 

bethh05

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I know this is just a tad late but in 2010 coding for exostosis removal changed to those in the bone cyst range.
 

nsteinhauser

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Oh no - never 'late' with additional information!

I know that in 2010 the 27640 (tibia) and 27641 (fibula) 'partial excision of bone' codes acquired the notes below them to point you to 27635 - 'bone cyst or benign tumor' - for exostosis excision of the tibia or fibula.

However, there are no such pointers underneath the 'partial excision of bone' codes in the foot codes.....

Do you know of any references that state this specifically for exostosis excision for the feet?

Thanks for your help.
 

BFAITHFUL

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I know this is late as well.... but this is very interesting because certain audit companies like TCN network are also stating this ....exostosis... code bone cyst/tumor exicision codes according to AMA, but I've never actually seen an article of any such thing from anywhere?
 

nsteinhauser

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Thank you all for your thoughts and input.

BFaithful - can you ask whoever was doing the TCN audit to supply some written documentation that says the AMA said that? That the exostosis removal should be coded with the 'bone cyst' removal code? Does the documentation then state the conditions -if any - where you would switch to the 'partial removal of bone' codes versus the bone cyst codes? At what point -and how would it be documented - does bossing off an exostosis not include shaving off some bone (ie - 'bone removal')along with it?

The 'coding buddhas' I've thrown this at say the same thing as Plaidman said above ...I can't assume anything from 'coding in another part of the body' - just because CPT directs us to use the bone cyst code for removal of exostosis IN THE LEG doesn't mean we should use the bone cyst code for removal of exostosis IN THE FOOT.....especially since the foot has other codes that are more specific (the partial removal of bone.)

If anyone else sees or hears anything, documentation-wise, I'd sure appreciate seeing it. Thank you all for your knowledge.
 

BFAITHFUL

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I'm sorry...I can't really do that.. because I only know that TCN states this because if you go to their website they have sample audit reports and in their sample audit reports that what is says about the AMA but I have yet to see such article with my own eyes. I am going to send in my question to the AMA directly and once I receive their response I will get back to you. I have done this in the past where I am really confused about a CPT code.
 

nsteinhauser

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Thank you, Bfaithful - I just found that sample audit you were speaking of - the one where TCN said the wrong code was used for excision of exostosis - 28112 - should have been 28104 -removal of bone cyst or benign tumor....and you're right - they say on that audit 'per the AMA'...... please keep us posted.
 

lizsergeant

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I'm sorry...I can't really do that.. because I only know that TCN states this because if you go to their website they have sample audit reports and in their sample audit reports that what is says about the AMA but I have yet to see such article with my own eyes. I am going to send in my question to the AMA directly and once I receive their response I will get back to you. I have done this in the past where I am really confused about a CPT code.
I am curious if you ever got a response from the AMA reagarding the use of 28122 vs. 28104?

Thanks.
 

nsteinhauser

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BFaithful - if you're out there - did you ever hear anything back about this?

I'm still wondering also, Liz. I still haven't found (from the AMA or anyone else) anything to substantiate the audit decision made by the TCN sample audit about the exostosis (see past entries.) I'm still going with what other podiatry coders have told me - an exostosis is not a 'cyst' per se ('cyst' implies fluid filled or blood filled....not solid bone), it's an overgrowth of bone, so 'partial excision (bossing, etc.) of bone' better defines it - the 28122 for metatarsal. 2012 CPT still refers you to 'use benign cyst code 27635 for exostosis' in the leg and ankle....but no such line referencing you to do this in the foot area. Confusing at best.

Please post if you find any answers - thank you.
 

Jamie Dezenzo

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Per CPT ASST

MAY 2011 CPT ASST

Surgery

Musculoskeletal System

Question

The patient was diagnosed with retrocalcaneal bursitis and Haglund's deformity of calcaneus. An inci-sion was made along the lateral aspect of the distal Achilles tendon and the tendon was reflected thereby expos-ing the calcaneus. The retrocalcaneal bursa was excised. Next, an osteotome was used to remove the Haglund's deformity down to the Achilles insertion. A rasp was used to ensure that there were no residual osseous spurs. Debridement of the necrotic area of the Achilles tendon was performed, and the incision was closed in layers with sutures. Is it appropriate to report CPT code 28120, Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus, for this procedure?

Answer

No. If a Haglund's deformity of the heel and retrocalcaneal bursa were removed, then code 28118, Ostectomy, calcaneus, should be reported. If additional work other than for exposure was performed on the Achil-les tendon, then that service would be reported as 28200, Repair, tendon, flexor, foot; primary or secondary, with-out free graft, each tendon. If there is a spur on the bottom of the foot and a plantar fascial release is performed, then code 28119, Ostectomy, calcaneus; for spur, with or without plantar fascial release, would be reported in-stead of/in addition to 28118. Code 28120, Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus, is typically performed for an infection and not for an exostosis, and only if a partial excision of the heel is performed.
 

bethh05

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Hello all, I inquired about the exostosis coding with Mr. Paul Cadorette of MD Strategies. He clarified that the notes under CPT 27640 and 27641 that direct you to 27635-Excision or curettage of bone cyst or benign tumor, also applies to other anatomical areas such as the foot.
 
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nsteinhauser

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Beth, If you speak with him again, could you ask - or maybe you know the answer to this - where is the documentation - from CPT or AMA, etc, - that specifies guidelines in one anatomical area should be followed in others? Coders I've talked to say not to do that.

But the only 'documentation' we have so far seems to point to the same conclusion - the CPT Assistant reference that Jamie added (above) says 28120 (partial excision of bone) 'typically is performed for an infection and not for an exostosis' ....
 

Jamie Dezenzo

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most current query

AMA Question
Date: 03/30/2012

Surgery

Musculoskeletal

Question

A parenthetical note under code 27640 states, “For exostosis excision, use 27635” (Excision or curettage of bone cyst or benign tumor, tibia or fibula). Can it be inferred that these codes may be used for any excision of exostosis or does the surgeon have to have docu-mented that the patient had a bone cyst or benign tumor?

Answer

An exostosis is a benign tumor; therefore, it is appropriate to report code 27635, Excision or curettage of bone cyst or benign tumor, tibia or fibula.
 

nsteinhauser

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Thank you for that update. I never would have defined 'exostosis' as being a 'benign tumor' ..... but there it is !
 

solocoder

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exostosis, again

Picking up an old thread here... It looks like AAOS recommends coding 28120-28124 for exostosis removal. I am wondering if payers tend to agree? If there is someone out there who codes it that way... could you share your experience with that, please?
 
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